**1. Introduction**

Throughout the early years of preschool education, parents and early childhood educators can use consistent patterns during the day so that children can practice literacy routines and health habits all together during mealtime, playtime, book time, nap time, and bedtime. Rhythms that form repeated patterns of movement, sight, sound, and language can bring engaging opportunities for literacy and health learning. Some professionals lack the interdisciplinary training to combine the domains of literacy and health into health literacy, but this chapter will build a vernacular that

#### **Figure 1.**

*Literacy influencers guide children's health experiences from their zone of proximal development by mediating health literacy events.*

will serve as a common language so that health literacy can be understood by more people. Thus, the complexities and realities of conceptualizing health literacy from childhood onward will have the greatest impact across the life course [1]. Suggestions to start the process of health literacy development at ages 6 to 12 years [2, 3] and during high school [4] have been promoted. Therefore, this chapter will make clear the need to start health literacy experiences earlier during preschool development so that children are prepared to enter kindergarten with opportunities to develop both functional and interactive health literacy skills more fully than are currently being realized.

**Figure 1** suggests that literacy influencers, such as peers, parents, and professionals, can scaffold preschool children's health experiences from their zone of proximal development by mediating health literacy events. Literacy influencers who guide children's health experiences from their zone of proximal development serve as significant role models to children by being the "guide on the side" during their ongoing language development. Language expressed in the form of oral language, written language, and body language [5] should also be woven rhythmically into a child's life so that language repertoires can continually influence their growing identity, agency, and independence.

The next section promotes the need to build health literacy events for children during consistent times of the day and the development of emergent literacy that leads to functional health literacy.

### **2. Build health literacy events for children during consistent times of the day**

Optimal development and learning for children from birth to age 8 years includes a "strength-based, play-based approach" with environments that are culturally and linguistically appropriate [6]. Daily literacy and health routines can be tightly

*Emergent Literacy Is Foundational to Health Literacy in Children: Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.113003*

structured and/or free-flowing, with the latter being more child-directed. Child independence and agency are core to early childhood educational outcomes. Freeflowing routines allow for uninterrupted play, self-regulation of social and emotional skills, and deeper engagement in learning [7]. One inquiry-based pedagogical model suggests that children can learn and practice habits of health each day with time for nutritious foods and beverages; physical activity, movement, and play; sleep, rest, and quiet time; safety and hygiene; and relationships [8]. Interdisciplinary connections between health habits and literacy events throughout the day can be implemented when children transition through changing intervals of mealtime, playtime, book time, nap time, and bedtime (**Figure 2**).

These integrated literacy events with health routines are a basic form of health literacy (**Figure 3**), which emerges from the concepts of literacy and health. The next section will describe the interdisciplinary domains that inform health literacy, including how emergent literacy is related to two forms of health literacy.

#### **2.1 Development of emergent literacy leads to functional health literacy**

Literacy has been recognized by pediatricians as a distinct developmental domain in children [9]. Thousands of pediatric healthcare professionals have incorporated literacy promotion into primary care with children and their families through its evidence-based program called Reach Out and Read. Reach Out and

**Figure 3.** *Interdisciplinary domains that inform health literacy.*

Read emphasizes the importance of parents reading aloud to their children every day and the value of book conversations for developing oral language skills while reading together. Emergent literacy is an informal acquisition of reading and writing skills that helps children get ready for school and leads to later success in reading [10]. Emergent literacy skills include phonological awareness, letter knowledge, and print awareness [11]. Reach Out and Read also recognizes the importance of literacy affordances by providing books for families to take home and start their home library of children's books.

**Figure 4** shows how emergent literacy leads to functional health literacy while influencing child identity and agency through a developmental process. Whereas emergent literacy does not have its roots in health, functional health literacy does. Functional health literacy is the ability to read, write, and speak about health. Child language and literacy professionals tend to describe literacy as reading and writing and refer to oral languages as separate from literacy outcomes [12]. Functional health literacy combines all three forms of communication with an added emphasis on health.

Children gain a health-related identity when they learn to think, act, and talk about their health and observe their significant others doing normative health behaviors. Children gain agency when they learn a vernacular to express themselves in healthy ways through oral language, written language, body language, and multimodal language. As children mature in their understanding of self and others, interactive health literacy is fostered. Agency is further developed with access to sociocultural opportunities for critical health literacy (**Figure 4**).

**Figure 4.**

*Emergent literacy leads to functional health literacy while building child identity and agency through a developmental process.*


#### **Figure 5.**

*Relationship between emergent literacy, functional health literacy, and interactive health literacy.*

Whereas **Figure 4** highlights identity and agency as foundations of the three types of health literacy, **Figure 5** shows the developmental process of emergent literacy, functional health literacy, and interactive health literacy from left to right. Emergent literacy is the knowledge about reading and writing, which a person knows before learning skills to read and write words. Emergent *multimodal* literacy highlights the fact that individuals can process information beyond words while communicating meaning through pictures, numbers, rhythms, and gestures. The concept of multimodal literacy has been promoted for early childhood [13] and K-12 education [14]. This article makes multimodality more explicit by renaming emergent literacy as emergent *multimodal* literacy, owing to its potential to be more inclusive of individual needs and abilities. In addition, by moving beyond a narrow focus on the linguistic mode, multimodality using visual, aural, gestural, and spatial modes is more compatible and inclusive for learners when interacting with digital, electronic, and print materials. Hence, interactive health literacy is defined

as interpersonal communication between people, including their interactive use of print and electronic materials to enhance health.

### **2.2 Preparing preschool children for health literacy in schools**

Health literacy was first used in 1974 as a call for health education standards in American schools for all grade levels [15]. Health literacy was later used as a subtitle for the "National Health Education Standards: Achieving Health Literacy" in 1995 [16]. In 2022, the National Consensus for School Health Education released the third edition of its model guidance for curriculum and instruction of the National Health Education Standards [4], which more fully conceptualizes a developmental model for health literacy.

Antecedents of health literacy are literacy and health-related experiences [17]. These two components establish the interdisciplinary connections between the domains of literacy and health to make health literacy. **Figure 6** shows the literacy and health-related affordances that facilitate the second type of health literacy called interactive health literacy. Notice that on the left side of the figure, literacy affordances include printed books, brochures, and newspapers, as well as electronic books, apps, and websites that children and their families access through literacy. On the right side of the figure, health-related affordances include access to fresh fruits and vegetables, water, toothbrushes, toothpaste, floss, reading glasses, hearing aids, and Braille devices so that all children have the physical supports and potential to become healthy.

**Figure 6.** *Affordances that facilitate interactive health literacy.*

*Emergent Literacy Is Foundational to Health Literacy in Children: Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.113003*

#### **Figure 7.**

*National Health Education Standards 1 and 3 show the relationship between comprehending functional health knowledge and demonstrating health literacy.*

Because interactive health literacy involves interpersonal communication among people, including an interactive use of print and electronic materials to enhance health, children will need to be supported on both sides of the affordance scale to become health literate. Hence, interactive health literacy moves children from individual identities into more agentic social identities when supported by interpersonal relationships, norms, and affordances. Multimodal literacies and language enable this transformational process of children's developmental journey from functional health literacy to interactive health literacy. As children learn about health in new contexts (e.g., schools, clinics, community agencies), there will be ongoing refinement to the dynamic rhythms between functional health literacy and interactive health literacy across the life course.

There is one other factor that prepares preschool children for health literacy in preK-12 schooling. **Figure 7** shows the importance of two National Health Education Standards (NHES) in developing functional health knowledge and health literacy. Functional health knowledge is defined as valid and reliable information and concepts that support health beliefs, skills, and behaviors [4]. Examples of these include knowing the benefits of eating healthy food and the characteristics of an emotionally healthy person [4]. Standard 1 of the NHES focuses on valid and reliable information and concepts needed to build an understanding of how to be a healthy child. In short, it focuses on *comprehending* functional health knowledge. NHES Standard 3 connects to NHES Standard 1 because students will need to access valid and reliable health information, products, and services to enhance health by *demonstrating* health literacy. The guiding principles and performance expectations for both of these standards including six other standards are available at https://www.schoolhealtheducation.org.

### **3. Conclusions**

This article highlighted how emergent literacy is foundational to health literacy in children, including the need for emergent multimodal literacies. Interdisciplinary connections from the domains of literacy and health form health literacy that can boost child health. Through a systematic approach, a visual-textual narrative described the need and rationale for establishing health literacy in early childhood education. Future work with preschool educators and parents will continue to elucidate the integrative steps needed to build literacy routines and health habits in tandem so children develop an identity and agency for health literacy. This enriched environment with adequate literacy and health affordances will help to support preschool children to enter kindergarten with opportunities to demonstrate their functional and interactive health literacy skills with a trajectory for further development in K-12 health education classrooms.
